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Fill and Sign the Fmla 497334634 Form

Fill and Sign the Fmla 497334634 Form

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FMLA Tracker Form Rolling Method – Variable schedule Employees Employee's Name ____________________________ SSN ___________________ Leave Request Dated ___________________ Reason for Leave ____________________________ 1. Beginning date of leave. ___________________ 2. Employee's average number of hours per week for the twelve weeks preceding the leave request ___________________ . 3. Employee's total leave allotment per twelve-month period (line 2 above multiplied by 12) ___________________ . 4. Total leave used in the twelve months immediately prior to date on line 1 ________ (if leave is taken in days or weeks, convert into hours based on the average set forth on line 2). 5. Remaining available leave (line 3 minus line 4) ________ . 6. Leave to be used this request (in hours) ________ . 7. Leave remaining after this request (Line 5 minus line 6) ________ . How to Use This Form Use this form only if you calculate leave usage under the rolling method and only if the employee at issue works variable hours. For employees with a set schedule, do not use this form. Complete a new form for each leave request.

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